Synopsis: In a multicenter randomized controlled trial, 304 patients who met specific inclusion and exclusion criteria were randomized to either a BNP-driven or physician-guided strategy for fluid management during ventilator weaning. Patients with renal failure were excluded because of the influence of renal function on BNP levels.

All patients in both groups were ventilated with an automatic computer-driven weaning system to standardize the weaning process. In the BNP-driven group, diuretic use was higher, resulting in a more negative fluid balance and significantly shorter time to successful extubation (58.6 hours vs. 42.2 hours, P=0.03). The effect on weaning time was strongest in patients with left ventricular systolic dysfunction, whereas those with COPD seemed less likely to benefit. The two groups did not differ in baseline characteristics, length of stay, mortality, or development of adverse outcomes of renal failure, shock, or electrolyte disturbances.

Bottom line: Compared with physician-guided fluid management, a BNP-driven fluid management protocol decreased duration of ventilator weaning without significant differences in adverse events, mortality rate, or length of stay between the two groups.

30-Day Readmission Patterns for MI, Heart Failure, Pneumonia

Clinical question: Do patterns exist among patients readmitted within 30 days of discharge for acute myocardial infarction (AMI), heart failure, or pneumonia that could provide insight for improving strategies aimed at reducing readmission rates?

Synopsis: Using CMS hospitalization data for principal diagnoses of AMI, heart failure, or pneumonia from 2007 through 2009, the authors examined the percentage of 30-day readmissions occurring on each day after discharge; the most common readmission diagnoses; the median time to readmission for common readmission diagnoses; and the relationship between patient demographic characteristics, readmission diagnoses, and timing. They found total readmission rates of 24.8% for heart failure, 19.9% for AMI, and 18.3% for pneumonia. Approximately two-thirds of 30-day readmissions occurred within the first 15 days after discharge for each cohort. Neither readmission diagnoses nor timing varied by patient age, sex, or race.

Although the majority of readmissions do occur soon after discharge, it is important to note that about one-third of all readmissions occur 16 to 30 days after discharge. There also was a diverse spectrum of readmission diagnoses that were not associated with patient demographic characteristics. These findings suggest that current post-discharge strategies aimed at specific diseases or time periods might only address a fraction of the patients at risk for readmission.

Bottom line: Among Medicare patients hospitalized for heart failure, AMI, or pneumonia, 30-day readmissions were frequent throughout the entire period, and readmission diagnoses or timing did not vary by patient age, sex, or race.

Synopsis: There has been limited research evaluating the correlation between physician workload and patient safety. An online survey compared the responses of 506 out of 890 enrolled physicians on the impact of average patient census and several outcome measures of quality of care. Some 40% reported that their patient census exceeded their personal safe workload at least once a month. They also reported that less time for patient evaluations led to fewer discussions with patients and family members, more unnecessary medical work-ups, and lower patient satisfaction.

A limitation of this study is that this electronic survey had the potential for selection bias. It also only measured perceptions of safety and quality, and only used standard daytime shifts (excluding night, cross-cover, weekend, and holiday shifts), which might have been associated with significantly different conclusions.

Bottom line: Increase in workload has a negative perceived impact on patient safety and quality of care for attending hospitalists.

Permanent Atrial Fibrillation Best Controlled by Diltiazem

Clinical question: Is there a difference between beta-blockers and calcium channel blockers for ventricular rate control and arrhythmia-related symptoms in patients with permanent atrial fibrillation?

Background: Rate control with beta-blockers or calcium channel blockers is recommended for the initial therapy of atrial fibrillation. However, studies comparing those drug classes or drugs within them are lacking.

Setting: Majority of patients from an atrial fibrillation outpatient clinic at Baerum Hospital in Norway.

Synopsis: The RATe Control in Atrial Fibrillation (RATAF) study included 60 participants with permanent atrial fibrillation. The goal of the study was to compare the efficacy of diltiazem at 360 mg/day, verapamil at 240 mg/day, metoprolol at 100 mg/day, and carvedilol at 25mg/day on ventricular heart rate and related symptoms in atrial fibrillation. Patients had a mean age of 71, atrial fibrillation for more than three months, and mean heart rate of 96 beats/minute. Exclusion criteria included the presence of congestive heart failure or ischemic heart disease with the need for other medications that could compromise the study.

From this study, diltiazem was shown to have the greatest effect in lowering heart rate, and those patients taking this medication had decreased symptoms related to atrial fibrillation. Hospitalists should not rely solely on this study for their treatment choice in all atrial fibrillation patients, but in certain populations, they should consider diltiazem as their first-line drug.

Bottom line: Diltiazem was shown to have the greatest reduction in heart rate and symptoms related to permanent atrial fibrillation.

Low-Dose Thrombolysis Effective in Moderate Pulmonary Embolism

Background: Studies have shown full-dose thrombolysis can effectively decrease pulmonary artery pressure in patients with massive PE. However, there are limited data regarding low-dose or “safe dose” thrombolytic therapy and its effect on pulmonary artery pressure.

Study design: Prospective, controlled, randomized study.

Setting: Single center.

Synopsis: The Moderate Pulmonary Embolism Treated with Thrombolysis (MOPETT) study enrolled patients with moderate PE, defined as signs and symptoms of PE plus computed tomographic pulmonary angiographic involvement of > 70% involvement of thrombus in ≥2 lobar or left/right main pulmonary arteries or high probability ventilation/perfusion scan (mismatch in ≥2 lobes). Patients in the thrombolysis group (n=61) were given low-dose tPA (100 mg tPA) and anticoagulation vs. the control group (n=60), which received only anticoagulation.

The study ran for 22 months, and the primary end points were pulmonary hypertension and recurrent PE. After analysis, low-dose thrombolysis was shown to significantly decrease pulmonary artery pressure and occurrence of recurrent PE compared to the control group.

This study demonstrates that, while the decision to use thrombolytics should always be made cautiously, hospitalists can consider low-dose thrombolysis in patients with moderate PE.

Diltiazem was shown to have the greatest effect in lowering heart rate, and patients taking this medication had decreased symptoms related to afib. Hospitalists should not rely solely on this study for their treatment choice in all afib patients, but in certain populations, consider diltiazem as a first-line drug.

High Mortality in Surgical Patients Requiring CPR

Clinical question: What are the incidence, characteristics, and 30-day-outcomes of CPR in surgical patients?

Background: Most studies of CPR are based on the medical population, and little is known about the utilization, risk factors, and outcomes of CPR in surgical patients.

Study design: Retrospective cohort study.

Setting: Two hundred fifty U.S. hospitals in the American College of Surgeons’ National Surgical Quality Improvement Program.

Synopsis: A total of 1.3 million surgical cases were studied in the data set. The overall incidence was 1 event per 203 cases. Most patients (77.6%) experienced a complication and did so on or before the day of CPR in three-fourths of cases. The incidence of CPR was the highest for cardiac surgery patients. Patients who received CPR had a mortality rate of 71.6%. Mortality rates of CPR patients increased with more comorbidities.

Additionally, older age and an American Society of Anesthesiologists (ASA) class of 5 was associated with higher mortality.

Limitations of this study included coding flaws in data collection, lack of capture of resuscitation-related injuries, and failure to account for changes in DNR orders.

Hospitalists should be mindful of risk factors contributing to CPR in surgical patients when performing perioperative evaluations.

Bottom line: Surgical patients who experience CPR have a high mortality rate, but many of these patients have pre-arrest complications that can be preventable.

Emergency Department Visits are Frequent Post-Discharge

Clinical question: What role do ED visits contribute to the overall use of acute-care services within 30 days of hospital discharge?

Background: Hospital readmissions within 30 days of discharge are a marker of the quality of care and reflect the effectiveness of the discharge process. ED visits are also a marker of hospital-based acute care following discharge, but little is known about the role of the ED during the post-discharge period.

Study design: Prospective study.

Setting: Acute-care hospitals in California, Florida, and Nebraska.

Synopsis: Using the Healthcare Cost and Utilization Project state inpatient and ED databases, all discharges between July 1, 2008, and Sept. 31, 2009, were evaluated for residents aged 18 years or older from three hospitals in three states. After exclusions, 5 million index hospitalizations among 4 million unique patients were studied.

Approximately 40% of the more than 1 million post-discharge acute-care encounters involved a visit to the ED.

Limitations of this study include that the data was derived from only three states, and only hospital-based acute-care visits were measured (i.e. visits to physician offices were not included). As hospitalists, we are responsible for discharges and care transitions. Being sensitive to the common medical conditions resulting in post-discharge ED encounters might improve care transitions.

Restrictive Transfusion Strategy Beneficial in Upper GI Bleeding

Clinical question: What is the hemoglobin threshold for transfusion of red cells in patients with acute upper GI bleeding?

Background: Controlled trials have shown that restrictive transfusion strategies (Hgb<7) are as effective as liberal transfusion strategies (Hgb<9) in critically ill patients. These studies have excluded patients with GI bleeding. In cases for which GI is not severe, the safest transfusion strategy is controversial.

Synopsis: A total of 921 adult patients with acute upper GI bleeding were enrolled and assigned: 461 to a restrictive transfusion strategy (hemoglobin<7) and 460 to a liberal strategy (hemoglobin<9). Patients with massive exsanguinating bleeding, acute coronary syndrome, peripheral vasculopathy, stroke, transient ischemic attack, lower GI bleed, recent trauma or surgery, or low risk of rebleeding were excluded. The primary outcome measure was the rate of death from any cause within the first 45 days.

Secondary outcomes included the rate of further bleeding and the rate of in-hospital complications.

Need for Non-ICU Acid Suppression Might Be Predictable

Clinical question: What are the risk factors for nosocomial bleeding in non-critically-ill patients?

Background: Acid-suppressive medication has been shown to reduce the incidence of nosocomial GI bleed in the ICU, but current guidelines recommend against its use in non-critically-ill patients. However, a subgroup of these patients might possess a high enough risk for GI bleed that prophylaxis is warranted.

Study design: Cohort study.

Setting: Academic medical center in Boston.

Synopsis: A total of 75,723 admissions of adult patients hospitalized for three or more days were included. Exclusion criteria included primary discharge diagnosis of GI bleed; principal procedure code of cardiac catheterization; and bleeding episodes occurring while in the ICU or within 48 hours of transfer out of the ICU. The primary outcome was nosocomial GI bleed (>24 hours after admission) occurring outside the ICU.

Nosocomial GI bleeding occurred in 203 patients (0.27%). Independent risk factors for bleeding included age >60, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulation, and coagulopathy. Based on the data, a scoring system was created that identified a high-risk group in whom the number needed to treat with acid-suppressive medication to prevent one bleed was 48.

The major limitations of this study are its observational nature and the need for validation of the proposed scoring system.

Synopsis: Highlighted changes include: 1) a single dose of pneumococcal 13-valent conjugate (PCV13) vaccine is now recommended for all individuals over the age of 19 with qualifying conditions; 2) clarification regarding pneumococcal polysaccharide (PPSV23) vaccine illustrates that high-risk individuals will receive up to three doses (one or two doses prior to age 65, plus an additional dose after the age of 65); 3) one dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is now recommended for all adults, including individuals age >65; 4) pregnant woman are advised to receive Tdap between 27 and 36 weeks’ gestation, with each pregnancy to provide protection to their newborn in the first months of life; 5) quadrivalent formulations of the live attenuated influenza vaccine (LAIV) and most likely the inactivated influenza vaccine (IIV) will be available in the 2013-2014 influenza season to increase cross-reactive protection against influenza B; and 6) both injection and noninjection illicit drug users are recommended to receive hepatitis A vaccine.

FDA LOWERS DOSE OF ZOLPIDEM

In response to data associating higher doses with significant impairment of next-morning mental alertness, the U.S. Food and Drug Administration is requiring manufacturers to decrease the recommended doses of Zolpidem.